What is the recommended dosing of Orapred (prednisolone) for a 2-year-old with an upper respiratory infection?

Prednisolone Dosing for a 2-Year-Old with Upper Respiratory Infection

For a 2-year-old child with an upper respiratory infection, prednisolone (Orapred) should be dosed at 0.14 to 2 mg/kg/day in three or four divided doses, with the specific dose determined by the severity of symptoms.

Appropriate Dosing Guidelines

The FDA-approved prednisolone dosing for pediatric patients varies depending on the specific condition being treated:

• For general pediatric dosing: 0.14 to 2 mg/kg/day in three or four divided doses (4 to 60 mg/m²/day) 1
• The dose should be individualized based on the severity of the upper respiratory infection and the child's response to treatment

Clinical Decision Making Algorithm

Step 1: Assess Severity of Upper Respiratory Infection

• Mild symptoms (minimal respiratory distress, good oral intake, no hypoxia)
  • Lower end of dosing range (0.14-0.5 mg/kg/day)
• Moderate symptoms (increased work of breathing, decreased oral intake)
  • Middle range of dosing (0.5-1 mg/kg/day)
• Severe symptoms (significant respiratory distress, poor oral intake)
  • Higher range of dosing (1-2 mg/kg/day)

Step 2: Determine Treatment Duration

• Short courses of 3-5 days are typically sufficient for upper respiratory infections
• Duration should be based on clinical response and resolution of symptoms
• No evidence that tapering the dose after improvement will prevent a relapse 1

Important Considerations

Evidence for Efficacy in Upper Respiratory Infections

It's important to note that the evidence for prednisolone use in simple upper respiratory infections is limited. The PREDNOS 2 trial found that administering 6 days of daily low-dose prednisolone (15 mg/m²) at the time of an upper respiratory tract infection did not reduce the risk of complications in children 2, 3, 4.

Additionally, a randomized clinical trial in non-asthmatic adults found that oral corticosteroids did not reduce symptom duration or severity in acute lower respiratory tract infections 5.

Potential Adverse Effects

• Short-term use: Increased appetite, mood changes, sleep disturbances
• Longer-term concerns: Growth suppression, immunosuppression, adrenal suppression
• Monitor for signs of adverse effects, particularly if treatment extends beyond 5 days

Common Pitfalls to Avoid

1. Overdosing: Exceeding recommended doses increases risk of adverse effects
2. Prolonged treatment: Extending treatment unnecessarily increases risk of adverse effects
3. Inappropriate indication: Using corticosteroids for viral upper respiratory infections without specific indications (like croup, asthma exacerbation, or significant airway inflammation)
4. Failure to consider alternatives: For simple upper respiratory infections, supportive care may be sufficient

Special Circumstances

If the child has asthma or reactive airway disease triggered by the upper respiratory infection, the National Heart, Lung, and Blood Institute recommends 1-2 mg/kg/day in single or divided doses until symptoms resolve or peak flow returns to 80% of personal best 1.

For croup-like symptoms with the upper respiratory infection, a single dose of dexamethasone (0.6 mg/kg, maximum 10 mg) may be more appropriate than a multi-day course of prednisolone.

Remember that most uncomplicated upper respiratory infections in children are viral and self-limiting, requiring primarily supportive care rather than corticosteroid treatment.